Considered pathologically there are three distinct conditions that must be considered under this head: (1) Fatty overgrowth, (2) fatty infiltration, (3) fatty degeneration. By most writers the first and second are considered together, as they usually intermingle, as one seldom exists without the other. For the sake of clearness I adopt the classification of Leyden, and I will consider them as distinct pathologic conditions.
Definition:—This condition is an increase in the deposition of sub-pericardial fat, until an excessive amount is deposited around the heart, forming an envelope, which may measure from an inch to an inch and a half in thickness. This abnormal accumulation seriously compresses the heart and materially interferes with its action.
Etiology:—It is a concomitant of general obesity and usually results from abnormal and slowly increasing corpulency.
Symptomatology:—The symptoms are mainly those of a weak heart in an obese patient. From compression of the heart the muscular fibers undergo atrophy and from educed contractile power greatly weaken the force of the heart's action. Any sudden violent effort produces general distress, dizziness, difficult breathing, palpitation, capillary stasis or cyanosis and fainting. The condition is found present in those who are indolent and are extravagant in their habits in eating and drinking, especially those who consume a large quantity of beer. The physical signs are largely negative, owing to general obesity, all. the sounds are muffled and weak, the pulse, however, is usually regular in beat, although occasionally intermittent. It is weak, easily compressible, usually large and soft.
Treatment:—The treatment depends upon the reduction of the general obesity and the results are not encouraging in advanced cases. If the fatty overgrowth has not induced changes in the heart structure the prognosis is favorable. There will be no indications found for specific treatment. Any course advised to reduce the fat should not lower the vital tone of the system, reduce the general strength or impair the health of the patient. Phytolacca decandra, in conjunction with collinsonia or hydrastis, will be found to produce good results. The use of bladder wrack is suggested in this disease when there is general torpidity of the system, with extreme inactivity and muscular relaxation. The iodids have exercised a beneficial influence in a number of cases.
This term designates a condition which differs from both overgrowth and fatty degeneration in that there is a deposit or infiltration of fat cells between the muscular fibers in the myocardium. This may be associated with fatty overgrowth; in fact, is seldom found alone. The muscular fibers are not changed in character except when prolonged compressio.n results in atrophy.
Symptomatology:—So closely is this condition allied to fatty overgrowth—it being dependent upon much the same conditions—that it is practically impossible to distinguish between them during life. In this condition there is apt to be dilatation of the heart and irregularity of its action. The immediate symptoms are sudden and severe exhaustion from the least violent muscular exercise, vertigo, palpitation, asthmatic breathing, syncope and great distress in the precordial region, amounting soon to angina. While some hypertrophy is always present it cannot be distinguished in the presence of fatty overgrowth.
Prognosis:—A judiciously conducted course of treatment will ameliorate the symptoms in some cases, or at least postpone a fatal issue. A complete cure is seldom accomplished.
Treatment:—The course of treatment is the same as that advised for fatty overgrowth, with the additional suggestion that possible changes in the heart structure may demand the use of cactus to promote an improved nutrition of that organ.
Definition:—In this disease the fat cells actually replace the structural elements of the muscular fiber, the fiber being converted into fat, at first perhaps in part only, but ultimately throughout the entire length of the fiber. The condition may be located in a restricted portion of the heart wall, or there may be a number of affected areas. In extreme cases it is almost universal, producing a friable or a greatly softened condition of the organ.
Etiology:—The condition follows obstruction of the coronary arteries when there is a tendency within the system to a general deposit of fat. It is common among alcoholics and in patients suffering from some forms of Bright's disease, especially chronic interstitial nephritis. It is also present in persistent anemia, especially in the pernicious type, and where the oxygen-carrying power of the blood k greatly impaired. In general tuberculosis in the cancerous cachexy and in phosphorus poisoning. It is often present in cardiac hypertrophy and may occur more or less rapidly in cases of acute infectious disease, which are greatly prolonged. The difficulty occurs more frequently among males than among females, and is seldom found in patients under forty-five years of age.
Symptomatology:—In the early stage of either form of fatty heart a specific diagnosis is exceedingly difficult. With degeneration, however, dilatation, because of pronounced muscular weakness, begins early and its phenomena will soon appear. With this there is also a cool or cold skin and cold extremities. The patient is irritable and suffers from mental depression and despondency. The dilatation, which may not be apparent even after other marked heart symptoms are present, may, from unusual violent muscular exertion, become greatly increased at once with a train of alarming and distressing symptoms. Usually, however, dilatation occurs more slowly with a gradual development of characteristic symptoms. There is extreme palpitation, with faintness, described as a sensation of smothering around the heart, dizziness and difficult breathing. The symptoms of quickly occurring breath-lessness on little exertion, with a tendency to faint, are common symptoms of fatty degeneration. While the heart is usually feeble and compressible in character it does not generally become irregular or intermittent until in an advanced stage of the disease. Brachycardia, however, is very apt to exist, the pulse running as slow as from thirty-five to fifty per minute. It is not uncommon in a class of these cases for a patient to become mentally deranged or to exhibit delusional insanity. In the later stage of the disease there are apoplectic or pseudo apoplectic attacks, associated usually with Cheyne-Stokes breathing, or a mild form of epilepsy may occur. Auscultation gives no pronounced evidences, the heart sounds are very feeble, the first sound being almost inaudible.
Prognosis:—These cases do not recover. Death may follow slight muscular exertion, or it may occur with no premonitory symptoms. A patient who has been conversing from his chair but a moment before may be observed to suddenly show violent facial contortion, with a painful effort at respiration, a clutching at something with the hands, staring of the eyes, purplish countenance, and death, or he may be, as is commonly the case, found dead in his bed in the morning.
Treatment:—To prevent fatty degeneration the strictest attention should be paid to the conditions which underly it, and constitutional measures should be adopted for its prevention. Every apparent dyscrasia must be promptly corrected, anemia must be overcome and a full normal quantity of red corpuscles must be restored. This will necessitate the use of our best tonics and restoratives under the most favorable hygienic conditions. If dilatation is apparent early, before the muscle fiber has actually degenerated, the use of remedies to inhibit further dilatation and put the muscle in the best possible tone, is highly essential. Hydrastis and cactus and digitalis, the former to sustain the nutrition of the heart, and the latter to exercise a contracting influence upon the muscular fibrillae and thus prevent further dilatation, are important remedies. Strophanthus in small doses will act similar to digitalis in this influence. Collinsonia and also crataegus are important remedies in this condition. They should be given with confidence and persisted in.